Spotlight Interview: Advocate Illinois Masonic Medical Center

At Advocate Illinois Masonic Medical Center, we have two dedicated electrophysiology labs. We have one primary group of electrophysiologists consisting of seven physicians who perform procedures in either of our labs. They also are the primary operators of EP procedures at three other hospitals in the Chicago Metropolitan area. There are several other groups of cardiologists/electrophysiologists who periodically perform procedures in our labs as well. We also have active outpatient and a device follow-up clinics. We have a staff of five full-time registered nurses, one of which functions as a laboratory manager/clinical coordinator. There are also two part-time registered nurses and a cardiology technician who does pacemaker transtelephonic monitoring. Additional resources include a dedicated research nurse, an office nurse and three secretarial staff, and an EP program coordinator. There are 2 dedicated EP fellows and at least one cardiology fellow rotating on the EP service at all times.

What is the mix of credentials at your lab?

The seven main physicians are board certified in clinical cardiac electrophysiology. The registered nurses all have critical care and cardiology backgrounds. They are all ACLS certified and credentialed in conscious sedation.

When was the EP lab started at your institution?

Dr. Richard Kehoe and Dr. Terry Zheutlin, who moved their practice from one of the leading university hospitals in Chicago in 1989, started the electrophysiology program at Illinois Masonic. Since then, the program has grown to its current level of seven electrophysiologists. Dr. Kehoe is the director of the program, Dr. Zheutlin heads the outpatient clinics and Dr. Nazari is the director of the EP laboratories. We have always had a dedicated, ACGME-certified EP fellowship program, currently under the direction of Dr. Pradeep Maheshwari, training 1-2 new fellows each year.

What types of procedures are performed at your facility?

We are involved in several research protocols and also serve the Midwest area as a referral site. Consequently, we perform radiofrequency ablations for many types of complex arrhythmias including ventricular tachycardia, pulmonary vein isolation for atrial fibrillation, scar-mediated atrial and ventricular tachycardia, modified right atrial maze procedures, WPW, AVNRT, atrial flutter, etc. We perform these, both as the primary referral center, and when other local EP labs refer them after failures or recurrences. We also implant pacemakers, implantable cardioverter defibrillators and biventricular devices. We do lead extractions and non-invasive procedures such as tilt table testing, NIPS studies on ICD patients, internal and external cardioversions and emergency temporary pacemaker insertions. In the past three years, Dr. Nazari has guided a special focus on the treatment of atrial fibrillation by atrial linear ablation and pulmonary vein isolation. This past October, we performed a pulmonary vein isolation procedure with Dr. Nazari and Dr. Maheshwari, live on a worldwide webcast. It was narrated by Dr. Kehoe. Dr. Nazari is our center s principal investigator in the Cardima right atrial linear ablation for treatment of atrial fibrillation. We utilize the Endocardial Solutions advanced mapping system and the CARTO advanced mapping system. Dr. Nazari is also our center s principal investigator in the CryoCath FROSTY trial of cryoablation for treatment of SVT. We were the highest enrolling center for that trial and had excellent success rates with cryoablation of AVNRT and AVRT.

Approximately how many are performed each week?

In 2002, we performed 709 procedures in the electrophysiology lab at Illinois Masonic.

What complications do you find during these procedures?

Our complication rate is well within or below accepted national standards. We have a nurse who collects and maintains outcome data on all our procedures and gives monthly quality assurance reports to our physicians as well as to the EP program director and the Illinois Masonic Hospital administration. The data are reviewed and analyzed carefully by our program director and presented in multidisciplinary meetings.

How is your EP lab managed, and by whom?

A nurse manager/clinical coordinator who is responsible for the flow of the labs and the outpatient clinic manages our EP.

Is the EP lab separate from the cath lab?

Our EP labs are distinctly separate from the cardiac cath labs in our facility. We are located geographically next door to one another, but our managers and staff members are entirely separate.

How long has this been?

This has been the case since the inception of the EP labs here in 1989.

Are employees cross-trained?

Our staff members are not cross-trained with the cath-lab since we function as two entirely separate entities.

Do you have cross training inside the EP lab?

All our nurses are cross-trained in the outpatient device clinic as well as all the procedures performed in the electrophysiology laboratories. Our nurses are trained to use all computer equipment, specialty technologies, as well as all the device programmers. The nurses also rotate the position of in-hospital clinical service nurse with the physician who is scheduled to see in-house patients. The nurse then provides all pre-op and post-op teaching, makes patient rounds with the physicians and fellows each day, provides liaison between the patients and physicians if they are in procedures, and sets up outpatient follow-up as well as discharge planning. She keeps a daily log of patient events, recording them in our database, reviews labs and diagnostic tests with the physicians, and plans follow-up with our outpatient nurse.

What new equipment, devices and/or products have been introduced at your lab lately?

We have been using the Endocardial Solutions and CARTO advanced mapping systems, the Acuson intravascular ultrasound system, the CryoCath catheter ablation system (research protocol), the CHILLI ablating system, the EP Med System electrophysiology system. We have performed biventricular pacemaker and defibrillator implants.

How has this changed the way you perform those procedures?

It has been very exciting for all our staff to be involved in these new procedures especially when we see the immediate impact it has on our patients. In terms of preparing the patients, the new technology is explained carefully to them. Patient preparation changes as the technology demands. Because these advanced mapping systems tend to be utilized for patients with arrhythmias who have failed conventional methods of mapping and ablation, they tend to be more time consuming and labor intensive. Cryoablation has established a new method of treatment of SVT in our lab, particularly useful in the area around the AV node.

Is your EP lab filmless, or does it plan to become filmless in the foreseeable future?

Our EP lab is not currently filmless, but we are very hopeful that we will become filmless in the not too distant future. Hope springs eternal.

Who handles your procedure scheduling?

We have a central board in our outpatient office where we schedule procedures. Because our physicians service other facilities, it requires careful scheduling to maintain all the labs and the outpatient clinics. Our clinical coordinator and outpatient office physician corroborate frequently during the week as physicians schedule cases and careful coordinating must be done.

Do you use particular software?

Dr. Jose Nazari and one of our part-time nurses wrote and designed the application that runs our EP lab and all other EP labs in which they work. Through it we follow all clinical, electrophysiologic, and procedural data on outpatients and in-patients. We also track the data from pacemakers and defibrillators in it. We generate our reports, clinical notes, tracking logs and monthly assessment of outcomes through it.

How do you handle physician timeliness?

We expect our physicians to be on time for procedures as planned. For one physician, however, who seems chronically stuck in his driveway, we charge a fee of 25 cents per quarter hour that he is late and save it in a piggy bank. By the end of the year, we plan to have enough to take our entire group on a Caribbean cruise. We did consider carefully the idea of beating him silly but, unfortunately, we found our hospital has a strict policy prohibiting this type of action. You can imagine our disappointment.

How is inventory managed at your EP lab?

Our clinical coordinator manages inventory. All ordering of supplies through our central supply and general stores department is done by one of our nurses and catheters, devices, and our coordinator orders anything out of the hospital supply chain.

Who handles the purchasing of equipment and supplies?

Our EP lab clinical coordinator works with the program and medical directors on the purchasing of new equipment for the lab. Supplies and inventory are managed as well by the lab coordinator.

How has managed care affected your EP lab and the care it provides patients?

There is a greater emphasis on getting patients scheduled and treated in a timely manner. Sometimes, if a patient s arrhythmia is tolerated well, they may opt to come back as an outpatient to be treated rather than stay if it means waiting a day.

What measures has your EP lab implemented in order to cut or contain costs and improve efficiencies in patient through-put?

All lab work is done ahead of time on an outpatient basis and patients are admitted the morning of their procedure. After their procedure they stay for six hours and then are discharged depending on their status, of course.

Does your lab have an outpatient program? 

We have an outpatient program where patients are seen and evaluated three days a week. Here patients can get their devices checked as appropriate, and be seen by a physician as well. New patients are evaluated and scheduled for procedures.

Has your EP lab recently expanded in size and patient volume, or will it be in the near future?

With our merger into the Advocate Healthcare system, we have several new EP physicians performing procedures in our labs, so our patient volume has increased. We have not expanded physically in size although our acquisition of new equipment has created some interesting challenges in terms of furniture arrangement.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area? 

The Chicago area healthcare market is quite competitive, with some of the best healthcare systems in the country competing for patients within a relatively small geographical area. Two years ago, our hospital joined the Advocate Healthcare System, which encompasses seven other hospitals and covers Chicago and the surrounding suburbs. Our alliance with this healthcare system has enabled us to achieve better pricing and purchasing abilities with vendors.

How are new employees oriented and trained at your facility?

Our new staff members are precepted and mentored by our current staff and clinical coordinator. They have an orientation and competency book, which they fill out as they achieve goals and master skills. They attend classes and inservices offered by the vendors for both EP and devices. However, the majority of their education comes from hands-on experience and the expertise of our physicians who patiently answer questions and often provide one-on-one EP study or ECG analysis after the case is over or in down time. Because our program involves teaching and training fellows, we all benefit from the knowledge and dialogue shared by our physicians, fellows, and nurses during live cases. We also have a weekly journal club and EP conference that we all try to attend to go over cases, clinical and research issues and analysis of electrograms and journal articles pursuant to our practice.

What types of continuing education opportunities are provided to staff members?

Continuing education is strongly encouraged in our group and new ideas and methods of treatment are approached with enthusiasm. Our physicians take advantage of the many opportunities offered them to be trained in new techniques such as biventricular device implantation, pulmonary vein isolation, cryo-catheter ablation, etc. The nurses go to as many inservices as possible offered by vendors to support these new techniques and understand the goals and procedures involved in offering new technology to patients. Since we provide much of the pre-op and post-op teaching to the patients and their families, it is essential that we understand the goals of the new therapies and the expected outcomes.

How is staff competency evaluated?

Our staff is evaluated annually according to the hospital guidelines. We all maintain current CPR and ACLS certification and conduct ongoing evaluation of competencies such as radiation safety, conscious sedation, infection control, universal precautions, etc.

Does your lab utilize any alternative therapies to help patients in the EP lab?

We work with patients to relax during procedures continually providing support and letting them know where we are in the procedure and what they can expect to feel, etc. We utilize relaxation-breathing techniques. However, we have found that what makes our patients feel most comfortable is the camaraderie they sense between the physicians and the nurses and they feel comforted by the fact that we are all so calm and confident in one another. Many of our patients have commented on this after the procedure is over. We play the patients choice of music before we begin anesthesia to help them relax. For the majority of our patients, having a nurse stand by them during the procedure explaining to them what is going on and what they can expect to feel is comforting and usually enough to help them relax.

Have you had any interesting or bizarre cases come through your EP lab?

Since we serve as a referral center for many hospitals throughout Illinois, we very often have cases that are interesting from an arrhythmic standpoint. Since we reside in a major metropolitan area, the bizarre and unusual cases are too numerous to mention. Our holiday parties are often filled with anecdotal reminiscing about the odd requests we have received and our physicians humorous responses to them. We did have a very interesting young patient who had not one but three concealed accessory pathways. Every time we ablated one we would uncover another. But after patiently ablating all three, we discharged him right into the hands of law enforcement officers who were waiting to arrest him. He is now serving his sentence in the state penitentiary and in beautiful sinus rhythm.

How does your lab handle call time for staff members?

We do not have call time for our staff members. It had been scheduled in the past, but since the number of calls was so infrequent, it became more cost-effective to discontinue the program. Occasionally, we have cases that require we come in on the weekends and the nurses who volunteer to support these cases are rewarded handsomely.

What types of quality assurance/quality control measures are practiced in your EP lab?

We keep very specific documentation of all our procedures both for research and quality assurance/control purposes. Our medical director reviews our QA statistics each month and any cases where there were complications.

Is your lab currently involved in any clinical trials or special projects?

We are currently involved in the CryoCath clinical trial of treatment of SVT with the Freezor catheter. We have been involved in SCD-Heft, AFFIRM, Cardima AF maze, Rhythm catheter intracardiac defibrillation, DAVID and MUSTT and are scheduled to be part of MUST II and other trials. We were deeply involved in the past in the initial trials of sotalol and d-sotalol under the direction of Dr. Kehoe. We were involved in the early trials of IV amiodarone and aqueous amiodarone, as well as other drug trials. We have been very interested in all clinical trials related to the treatment of atrial fibrillation in particular due to the preponderance of this rhythm in the general population and its overall impact on the healthcare system and the patients themselves.

Does your lab undergo any sort of inspection? How often does this occur?

Our labs undergo bi-yearly JCAHO inspection, IDPH inspection, radiation safety inspection and semi-annual clinical engineering inspection. Thankfully, due to the organizational neurosis of our nursing staff we have always passed these inspections with flying colors.

Does your lab provide any educational or support programs for patients who may have additional questions or those who may be interested in support groups?

The nurses and physicians provide a lot of education to patients and their families before procedures or the implanting of a device as well as written materials and videotape. We listen carefully to their questions and concerns and try to provide as much education and support as possible. Sometimes this involves one-on-one sessions with the physicians or the nurses or both as the need arises. If requested, we try to match our newly implanted ICD patients with other patients in their age group who have had their device for a while and adjusted well. Often they talk and provide support to one another. We had a support group called Tachbusters, and had meetings for patients and their families quarterly along with a newsletter sent to all the patients following the meeting. We would have physicians, dieticians, psychologists, physical therapists and cardiac rehab physiologists speak at these meetings.

Is there a problem or challenge your lab has faced? How it was addressed?

One of our most bizarre occurrences happened at a support group meeting. Our Clinical Coordinator had arranged a special meeting for all of our ICD patients under the age of 50. She felt they needed a different kind of support and were often isolated because of their young age, so she arranged for a psychologist to speak. The meeting was held at the psychologist s conference room, (where they also offered yoga and relaxation classes), requiring all the participants and nurses to remove their shoes and place them outside the door. By chance, one of the participants received a shock as he was speaking to the group and all the other participants sprinted out of the room within a matter of seconds. In his haste, one of the patients left in the psychologist s shoes instead of his own.

Please tell our readers what you consider unique or innovative about your EP lab and staff.

Our Director and Clinical Coordinator actively participate in the daily operation of our laboratory, which enhances our ability to address any problems or challenges quickly and effectively. Fortunately, all our staff members are never hesitant to present us with an opportunity for growth, which assists us in prompt identification of problems and we work together on resolution. Because we have been so fortunate to have had the same staff members over the past 4-5 years with very little turnover, we have become a working family in the sense that we have learned to respect each other and accept one another s idiosyncrasies. Given the fact that we spend more time with each other than our own families, this aspect of our working relationships has become critical. Very often we can guess what each other is thinking without even speaking. Most of all, we all enjoy the continually changing and growing field of electrophysiology, which may be challenging, exasperating, and frustrating at times, but can also be immensely rewarding and is certainly never boring. As we like to say working with our group, puts the ‘fun’ in dysfunctional.